**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (CR #1) out of 3 residents reviewed for quality of care in that: The facility failed to ensure oxygen was administered to CR #1 when her oxygen saturation went down to 81% on [DATE]. The facility failed to assess CR #1's vital signs during change in condition on [DATE]. The facility failed to ensure CR #1 was sent to the hospital promptly, approximately more than an hour delay, when CR #1 had change in condition on [DATE] resulting in delayed care/intervention. A private ambulance was used instead of 911 which contributed to delayed care, and the family requested CR #1 to be sent to the hospital. CR #1 continued to deteriorate and expired at the hospital on [DATE]. The facility failed to follow up and perform intervention on CR #1's abnormal lab values. The facility failed to follow up and schedule an appointment for CR #1's amputated wound as recommended by the Wound Care Doctor. An Immediate Jeopardy (IJ) situation was identified on [DATE] while the IJ was removed on [DATE] at 9:52 AM, the facility remained out of compliance at a scope of isolated with actual harm that was not immediate, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could expose residents to low quality of care, worsening of condition, hospitalization, and death. Findings included: Review of CR #1's face sheet date revealed a [AGE] year-old female who was admitted to the facility on [DATE]. CR #1's diagnoses included peripheral vascular disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), atrial fibrillation (An irregular, rapid heart rate that commonly causes poor blood flow), presence of cardiac pacemaker (A device used to control the heartbeat which stimulates the heart as needed to keep it beating regularly), essential primary hypertension (hypertension occurs when you have abnormally high blood pressure that's not the result of a medical condition), atherosclerotic heart disease (disease caused by the buildup of plaque causing coronary arteries to narrow and limiting blood flow to the heart), end stage renal disease (the final permanent stage of kidney disease when the kidney can no longer function), left above-the-knee amputation, type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), hemorrhage (bleeding), anemia (A condition in which the blood doesn't have enough healthy red blood cells), and Pancytopenia (low levels of all three blood cell types-red blood cells, white blood cells, and platelets). Review of MDS assessment dated [DATE] revealed CR #1 had a BIMS score of 11. CR #1 required substantial/maximal assistance with bed mobility and was dependent for transfers. MDS section M also revealed CR #1 had pressure ulcer and surgical wound. Review of care plan dated [DATE] revealed CR #1 had a post-surgical wound to the left thigh, the goal was the wound to be free from infection and heal, intervention included monitoring for signs and symptoms of infection, refer to follow up with surgeon as needed. Care plan also revealed CR #1 had arterial wound to the left medial thigh with the goal of pain will be relieved within one hour of intervention and no circulatory concerns will occur, intervention included to provide treatment per order and keep area clean. Care plan also revealed CR #1 had a stage III pressure injury to left lower back with goal that resident will have no complications from wound, and skin will remain clean, dry, and will heal through the next 90 days. Review of SBAR dated [DATE] by Nurse A revealed CR #1 had a change in condition with shortness of breath and in pain with new onset necrosis and fluid filled blisters. Oxygen saturation was 81%. The time of the oxygen saturation assessment was at 4:00pm on [DATE]. Vital signs on the SBAR were from previous days ([DATE] and [DATE]). SBAR also revealed CR #1's family at bedside with resident and suggested resident to go to the hospital. Review of lab dated [DATE] revealed CR #1's abnormal labs - white blood cell count was 13.0 (reference range was 4.0 - 10), RBC 2.68 (range 3.93 - 5.22), Hemoglobin 8.8 (range 11.2 - 15.7), Hematocrit 30.5 Review of CR #1's order for the month of October and [DATE] revealed lab order [DATE], on there was no other follow up lab ordered for the rest of CR #1's stay at the facility. Review of vital sign for [DATE] revealed oxygen saturation of 81% at 4:00pm and 81% at 4:03pm, there were no other vital signs documented for CR #1 on [DATE]. CR #1's vital sign on [DATE] was blood pressure = 100/70 at 11:59am and 106/56 at 6:00pm; pulse=104 bpm, no oxygen saturation assessed. Pain rating was documented as 0 on [DATE], [DATE], and [DATE]. There was no pain rating documented on [DATE] and for the rest of the days that CR #1 was in the facility. Review of private ambulance report dated [DATE] revealed the call was made to the ambulance service at 3:38pm on [DATE]. The ambulance service arrived at the facility to pick up CR #1 at 4:18pm on [DATE]. The report also revealed the resident was complaining of pain, a blister, and tenderness to her right leg. The report revealed CR #1 stated she had an amputation about a month ago and that in the past week the pain, tenderness, and blistering has gotten worse. The assessment showed that CR #1 was hypotensive and tachycardic (rapid fast heartbeat). The ambulance record did not reveal if oxygen was administered to CR #1. The ambulance arrived at the hospital at 4:48pm on [DATE]. CR #1's care transfer from the ambulance service to the ER was made at 5:41pm. Review of the hospital emergency room record dated [DATE] revealed CR #1's time of arrival at the ED was 4:52pm. CR #1 complained of leg pain x week. CR #1's Blood pressure enroute to the hospital was 88/50. CR #1's vital signs at ER at 5:18pm were blood pressure 88/50, heart rate = 117, respiration 17, and oxygen saturation 99%. The record did not indicate if oxygen was administered. The vital signs at 6:10pm were blood pressure = 73/56, heart rate = 119, respiration 20, and SpO2 = 95% on room air. The vital signs at 6:15 were blood pressure = 66/50, heart rate 120, respiration = 22, and SpO2 = 98% on room air. At 6:21pm CR #1 triggered for sepsis (the body's extreme response to an infection, when an infection triggers a chain reaction throughout your body). The vital signs at 7:15pm were blood pressure = 72/52, heart rate 108, respiration = 20, and SpO2 = 96%. The vital signs at 8:00pm were blood pressure = 78/49, heart rate 84, respiration = 21, and SpO2 = 94%. The record revealed at 8:03pm CR #1's heart rate went down to 40, respiration went down to 10, and oxygen saturation was 86%. The hospital emergency room record also revealed CR #1's was having a slowly worsening bradycardia, CR #1 had no palpable pulse, and CPR was initiated. CR #1 was pronounced dead at 8:33pm. Review of the hospital Emergency Department record dated [DATE] revealed CR #1 was at the hospital for leg pain and concern for infection at recent amputation site to lower left extremity . On [DATE] at 3:11pm in an interview with Nurse A who was taking care of CR #1 on [DATE], she stated she did not remember if she checked CR #1's vital signs on [DATE]. The State Surveyor asked how Nurse A completed her SBAR and which vital signs she recorded in the SBAR, Nurse A stated she did not know. Nurse A stated the medication aide was supposed to check CR #1's vital signs because CR #1 was getting blood pressure medication. She was not aware that the vital signs were not checked by the Med Aide, the Med Aide was supposed to check residents' blood pressure during medication administration. Nurse A said vital sign helps to know how residents are doing, and if there was anything going on, it would reflect in the vital sign and prompt intervention would be provided. she stated she did not remember if she administered oxygen to CR #1 when her oxygen saturation dropped to 81%. She said it's been a while and she did not remember. She stated she did not remember the exact time the EMS was called, and she did not remember the time they arrived at the facility. On [DATE] at 3:24pm the Wound Care Nurse said CR #1 was admitted with wounds - post-surgical wound on the amputated left stump, necrotic wound above the stump, and sacrum wound on admission which got worse. She stated she was dressing the wounds everyday and the Wound Care Doctor was seeing CR #1 too, she stated the doctor comes to the facility every week. She stated there was no specific treatment for the right foot with discoloration. The Wound Care Doctor told them to keep monitoring it. She stated she did not notice any signs of infection on the wound, no warmth to touch, no redness, and she said CR #1 did not even complain of pain to the wounds. On [DATE] at 3:37pm, in an interview with the Unit Manager , she stated she did not know if the resident was given oxygen. She said she was busy with another resident and was not present in CR#1's room at the time of the change of condition. She stated, we called 911 right away. The Unit Manager stated they took vital signs of all residents at every shift, especially the residents admitted to the skilled unit. She stated CR #1 was admitted to the skilled unit and her vitals were expected to be checked every shift because vital sign is an important signal that tells if anything was wrong with resident at any time, if they did not check the vital signs they would not know if resident was exhibiting symptoms they could not see. She stated she was not aware that CR #1's vital signs were not checked on [DATE] specially at the time of the change of condition, she stated failure to assess vital sign could prevent resident from receiving prompt intervention. The Unit manager stated that the SBAR was supposed to be completed with the vital signs checked at the time of the change in condition. She stated they would notify the doctor when lab results came back and the doctor would review the lab results to determine if any orders were needed, and failure to do this could place resident in the risk of having abnormal labs for longer time and could affect residents' health status. On [DATE] in an interview with the DON , she said the practice in the facility and the expectation from all nursing staff were to check and document residents' vital signs every shift. She stated using a previous day vital sign to complete SBAR was not right. the resident had to be assessed at the time of the change of condition, and part of the assessment was to complete vital signs. The DON stated the nurses were expected to administer oxygen to the resident at any time when O2 saturation gets low regardless of whether the resident had order for oxygen or not because O2 sat of 81% is not good as this could place resident in hypoxia (a condition in which oxygen is not available in sufficient amounts at the tissue level to maintain health stability). She stated oxygen should be administered immediately, and the order could be obtained from the doctor later, because prompt intervention must be performed. The DON stated when the doctor ordered labs the expectation was that they would notify the doctor whenever they received the lab results. The DON stated I didn't know about all these because she was not employed at the facility at that time. She started working at the facility on [DATE]. On [DATE] at 4:34pm in a further interview with the Unit Manager we call 911 right away she also said we didn't want her to stay long, if we had called the regular transportation, it would take too long, so 911 is fastest for us and that's what we called she said sometimes it take up to 2 hours for the regular transport to come, so they had to use the 911. Said they do have vital sign on all residents everyday on the floor. Said they had been doing that since the onset of covid, said they always did vital signs on all residents on the halls. On [DATE] at 1:12pm an interview with the Family Member revealed there was no oxygen administered to CR #1 when she had shortness of breath. The Family Member said it took a long time, more than an hour, for the facility to call transport. The Family member stated he requested for 911 to be called. He said it was after a long time, they waited and waited, before the ambulance arrived and it was not a 911, it was a private company ambulance. On [DATE] at 4:11pm during an interview with the Doctor who was caring for CR #1, she stated CR #1's white blood count was coming down. The Doctor said it was 12 when she came back from the hospital on [DATE] and she was hemodynamically stable and clinically stable before she came back to the facility on [DATE]. The Doctor said she suddenly decompensated and became septic, and she decompensated in one day. The Doctor stated, I think it was a very rapid deterioration. It certainly did not happen incrementally over the week, otherwise we would have noticed it. She stated she was trying to remember now because she did not have access to CR #1's record after she had been discharged . She stated she did not remember if she gave any follow-up orders regarding the labs. She stated there was no indication in the record that CR #1 was infected based off her clinical status and her vitals. She stated, I am pretty sure that I ordered labs. She said CR #1 went to the hospital on [DATE] for suicidal ideation and she came back better. Her mental status was better. When she saw CR #1, she stated she wanted to get better, and she wanted to get out of the facility to go home. The Doctor stated the situation on resident's right foot happened in a day. She stated resident recently had an amputation and there was no infection. She said the wound care doctor was managing the wound and the wound care nurse was dressing the wound everyday. She said they would have notified us if there were any changes. The Doctor said CR #1 had a lot of comorbidities and when she got septic it happened really quick. The Doctor said she saw the residents at the facility once or twice per week. She stated the last time she saw the CR #1 was on Thursday [DATE]. She said at that time she was not aware that CR #1 had any issues with the right foot. She was made aware of the necrosis on the right toe and blister on the right leg on [DATE] at the time CR #1 was sent out to the hospital. The Doctor stated at the hospital before CR #1's initial admission, her WBC (White Blood Cell) count was on [DATE] = 25; [DATE] =23; [DATE] = 18.5; [DATE] =16.5; [DATE] =12.9; [DATE] =11.4. The Doctor stated she did not remember if the resident was admitted with antibiotics. She stated the resident was on cefepime until the 25th of October of 2023. The Doctor stated a WBC count was done at the facility on [DATE] and was 13. On [DATE] it was 12.2 at the hospital and on the day the resident died her WBC was up to 19. On [DATE] at 9:59am an attempt was made to interview Medication Aide A who was caring for CR #1 on [DATE], there was no response to the call. On [DATE] at 10:25am in a further interview with Nurse A - the nurse on the floor when CR #1 was having shortness of breath. She stated when you spoke with me the other time, it was just a lot and it had been a while and she did not remember everything, she said she saw a lot of patients everyday and she was not able to remember and needed time to process the information about the resident. She stated she actually did resident's vital sign on that day [DATE], but she did not input it in the PCC, she said I am sorry. She said she also had the patient (CR#1) deep breath and CR #1's oxygen went up to 90s, she said she did not recall if it was 91% or 92%. She said the time the Oxygen saturation was taken was at 4:00pm on [DATE] and she did all the vitals all together including the O2 sat. She stated lack of oxygen could cause a person to be dizzy, weak and could cause someone to pass out and lack of oxygen can cause death. She said the first thing she did when she went in there was to look at resident's skin because of what she was told about the fluid coming out of CR #1's leg. She said she assessed the resident head-to-toe, and then from what the assessment revealed with the low oxygen, and she saw the way the resident was breathing as resident was not breathing well, then she told the resident to deep breath and the oxygen went up to 91% or 92%. She said she sent resident to hospital because of pain - she said when they turned patient during head-to-toe assessment to look at her sacrum wound, the resident stated ouch and she knew that the resident (CR #1) had pain. On [DATE] at 12:14pm in a further interview with the Wound Care Nurse , she said she did not remember because it was a while ago and she had to recall what happened. She stated she was doing wound care on that hallway, and she peeked in to see if CR #1 was in the room and ready for wound care. There was a Therapist in the room with CR #1. She said the Therapist asked her if she saw the foot of CR #1 and she came into the room to look at the right leg. She said the Doctor (who was in charge of resident's care) saw the resident the day prior ([DATE]) and told her (Wound Care Nurse) to keep monitoring and if anything changed, they should send the resident out immediately. The Wound Care Nurse started on the following day ([DATE]), the discoloration progressed from the toes to the resident's ankle and there was a blister on the right leg too. She stated that was the reason why the resident was sent out to the hospital. The Wound Care Nurse stated she was not aware if the vital signs were checked at that time. She said the Therapist checked the resident's pulse ox and felt that the oxygen level was not right. She said she did not remember the specific value, but she remembered the O2 sat started around the 80s and went up to the 90s. She stated when the nurse came into the room the nurse also checked the pulse ox and she did not recall what it was. The wound Care Nurse stated she did not remember if the blood pressure and other vital signs were checked at that time or not. She stated she was trying to calm the patient (CR #1) down because CR #1 was not happy with how her foot looked with the progression of the discoloration. The State Surveyor requested for the Wound Care Doctor's contact from the Wound Care Nurse. On [DATE] at 10:11am in an interview with the Physical Therapy Assistant, she said on [DATE], she could not recall the exact time, she did exercise with the resident's left stump. When she wanted to do the exercise with the right leg, she lifted the leg, there was a [NAME] of fluid from the leg, so she stopped. She laid the leg on a towel to soak the fluid coming out of it. She checked the resident's O2 sat and it was 80%. She wanted to step out immediately to look for a nurse, but the wound care nurse and the floor nurse came in - the wound care nurse came in first, and she was explaining what she found about the '[NAME]' of fluid from CR #1's leg to the Wound Care Nurse and the Floor nurse (Nurse A) came in after. She said she handed over to the nurses who took over CR #1 from there. She stated she did not know anything that happened after. On [DATE] at 10:15am in an interview with the Occupational Therapist, he stated he went into the room earlier to do exercise with the resident (CR#1) but he noticed CR #1 was not looking good and appeared to be have labored breathing or in severe pain. He stated he did not really know, but the resident was not looking good to him and appeared to be in some sort of distress. He stated he immediately stepped out to get a nurse to check on CR #1. He said it was hard for him to find a nurse. It took him up to 20 minutes to get a hold of a nurse. He said he did not know who the nurse was because they had agency nurses in the building at that time and he did not really know them. He said when he got a nurse and came back to CR #1's room he met the Physical Therapist Assistant and the wound care nurse in the resident's room. He stated he did not do exercise with the CR #1. On [DATE] at 12:34pm another attempt was made to interview Medication Aide A who was assigned to CR #1 on [DATE], but there was no response. The State Surveyor left a message on the voicemail. On [DATE] at 5:20pm an attempt was made to contact the Wound Care Doctor, but there was no response. The State Surveyor left a message on the voicemail. On [DATE] at 8:58am in an interview with the Wound Care Doctor, he stated he had a concern regarding CR #1's stump, the left leg that was amputated. He said when he saw CR #1 on [DATE], he personally spoke to the Family Member 1 who was at the bedside, and Family Member 2 over the phone, and told them that the resident (CR#1) needed to follow up with the surgeon who did the amputation as soon as possible. He said he told them that the stump was not looking good, he said the stump appeared necrotic upon admission. He said he did not notice any infection in any of CR #1's wound. He said The amputation wound was compromised, he said she presented from the hospital with gangrene on the amputation stump and upon noticing that on my first visit I spoke to her, I called the family member. The Wound care doctor stated he also noticed during his first assessment on [DATE] that CR #1's right foot had discoloration from poor circulation. He said that he left the information with the Wound Care Nurse who was right there with him when he was assessing CR #1 and was speaking to CR #1's family members. The Wound care doctor stated he did not know if the resident made the appointment to the surgeon. He said I left that with the treatment nurse to follow up particularly for the amputation because the wound was not doing well regarding CR #1's right foot with discoloration, the Wound Care Doctor said he did not recall and had to look at his notes. He said there was not much treatment involved with that except to monitor it and that was my recommendation. He said it was a result of CR #1's poor circulation. On [DATE] at 9:23am an attempt was made to obtain further interview from the Wound Care Nurse regarding the recommendations from the wound care Doctor to schedule an appointment with the Surgeon for CR #1's wound. There was no response to the call. On [DATE] at 10:06am in an interview with Family Member 2, she stated someone spoke with her over the phone at the time CR #1 was just admitted to the facility, but she didn't know who it was. She said Family Member 1 was there at the bedside at the time the person, who she believed to be a doctor, was speaking with her over the phone regarding CR #1's wound. She said the doctor gave the recommendation that they needed to see the surgeon to follow up on the left stump because it was not looking good. She said, I also had a concern about that wound too, but I am not a doctor, I don't know anything. She said she spoke with the receptionist at the surgeons office who said the resident would be due for the two week follow up and the family member should go ahead and schedule the follow up appointment. The receptionist also stated they should take a picture of the stump, send it in to their office, and if there was anything wrong, they could get CR #1 in sooner. She stated she went ahead to schedule the appointment for two weeks, and the receptionist told her they needed to send in a picture for them to see how the wound looked. She said she was not there at the facility but Family Member 1 was there at the facility, and she told him (Family Member 1) to take a picture of the stump. She stated Family Member 1 said he took the picture, and he gave it to a lady who was one of the staff members (he did not know the name of the staff). She said when she came to the facility to visit CR #1 a few days later, she spoke to a lady who was dressing the wound of CR#1. She believed the nurse was the wound care nurse, and the wound care nurse said they had already contacted the surgeon, provided a picture of the stump, they spoke with the surgeon, and everything was fine. She said about a week later when she followed up at the surgeon's office, the receptionist told her that they never received any pictures. She asked Family Member 1 and he (Family Member 1) was upset because he said he took the picture and gave it to one of the staff along with the number of the surgeon's office so they could send the picture in to them. She stated CR #1 did not make it to the surgeon follow-up appointment before she passed. Review of policy titled 'Vital Signs' dated [DATE] revealed, in part, vital signs shall be obtained at least in the following circumstances . at least daily for a resident receiving skilled services .when the residents general condition changes. Review of policy titled 'Oxygen Administration' dated 10/2023 revealed in part, Oxygen is administered to residents who need it, consistent with professional standards of practice .and the resident's goals . Review of policy titled 'Laboratory Services and Reporting' dated [DATE] revealed in part, The facility must provide or obtained laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with the state law .Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of the laboratory results that fall outside the clinical reference range. This was determined to be an Immediate Jeopardy (IJ) on [DATE] The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 1:45pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 10:32pm. The plan of removal reflected the following: Plan of Removal Name of facility: Date: [DATE] F- 684 Problem: Failure to transfer a resident out promptly when there was a change in condition. 1. CR#1 no longer resides in the facility. 2. [DATE] The facility DON/Designee conducted an audit of the current residents' v/s to ensure all are free of changes in condition. Any issues identified were immediately addressed. 3. [DATE] The Licensed nurse assigned to the resident during the residents change in condition was placed on suspension pending investigation. The following in-services were initiated by the DON on [DATE]: Any nurse, or medication aide not present or in-serviced on [DATE], will not be allowed to resume their duties until in-serviced. Ongoing in-service will be completed by the DON, the Unit Managers, the WC nurse or the RN Supervisor, until all Licensed staff, medication aides, weekend, PRN, and agency staff have completed the in-service. In-service completion projected for [DATE]. 4. [DATE] The DON/Designee immediately initiated an in-service with the licensed nurses, including medication aides regarding what is a change in condition, resident assessment, nursing interventions, and prompt transfers. Licensed nurses will not be allowed to work until after completion of the in-service. Completed [DATE]. 5. [DATE] The DON conducted an in-service with the nursing staff including floor nurses and managers to overview the interventions a nurse must initiate in case of an emergency pending MD/NP call back/approval such as with hypoxia/hypotension episodes based on the facility Medical Director Protocol. Nursing staff will not be allowed to work until after completion of the in-service. Completed [DATE]. 6. [DATE] The DON conducted an in-service with the nurse management team on the facility expectations to assist floor nurses during emergencies including assessment, intervention, and prompt transfers. Nursing managers will not be allowed to work until after the completion of the in-service. Completed [DATE]. 7. [DATE] Re-in-service licensed staff, including medication aides on Immediately reporting sentinel events to the DON and/or the Administrator including but not limited to the residents' changes in condition, transfers, any allegations regardless of time or day. Licensed nurses will not be allowed to work until after completion of in-service. Completed [DATE]. 8. [DATE] The DON/designee began a questionnaire to validate effectiveness of the training. The questionnaire is conducted with Licensed staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion on the questionnaire. Completed [DATE]. Monitoring as of [DATE]: 9. [DATE] The DON or administrator is notified of all resident changes in condition, emergencies, and resident transfers to provide guidance and ensure proper assessment, interventions, and transfers are done appropriately. Issues identified will be immediately addressed through further education, disciplinary action, and or termination of employment. 10. [DATE] The DON/IDT reviews the SBARS and transfers out of the facility from the prior day at least 5x per week to ensure the process was appropriately followed. Any issues identified will be addressed immediately. 11. An impromptu QAPI meeting was conducted with the facility Medical Director, on [DATE] to notify of the potential for noncompliance and the action plan implemented for approval. Plan approved on [DATE]. 12. [DATE] The Administrator, DNS/Designee will report the findings to the QI process and QA committee monthly until deemed no longer necessary. Any concerns or recommendations will be addressed immediately. The State Surveyor confirmed the Plan of Removal for the IJ by monitoring from [DATE] through [DATE] as follows: On [DATE] at 2:12pm in an interview with Nurse B (the weekend supervisor), she stated she got a training this morning when she first got to the floor. She said the Administrator trained her on an in-service today [DATE], and the training was about vital signs. They must ensure to always check their residents vital signs every shift. They must check resident's blood pressure for blood pressure medications and document when blood pressure was taken. If the blood pressure was outside the parameters prescribed by the prescriber, the medication would be held (not given to the patient), and the reason for not giving it would be documented as well as the value of the blood pressure. She said she was also in-serviced to always see what happened when any of the nurses have issues with any of their residents and to go in there in person to see what was going on. On [DATE] at 2:20pm in an interview with Nurse C, she said she had training today ([DATE]). The training was about vital sign monitoring every shift and as needed. She said she had a training, about when to call a manager, or a supervisor in charge of the shift or in charge of the hall. She said the supervisor should be called when a resident had a change of condition, when

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 15 residents (CR #1) reviewed for cardio-pulmonary resuscitation. LVN A failed to initiate life-saving measures (CPR) when CR #1, who was on hospice and had a code status of full code (meaning the person wants all resuscitation procedures provided if their heart stops beating and/or they stop breathing), was found unresponsive and died. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 12:34 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents on full code status at risk of death from not receiving life-saving measures. Findings include: Record review of CR #1's face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with cerebral infarction (ischemic stroke; disrupted blood flow to the brain), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the brain), neurologic neglect syndrome (malfunction in one hemisphere of the brain), stage 3 chronic kidney disease (mild to moderate kidney disease), diabetes mellitus (too much sugar in the blood), hypertension (a condition in which the force of the blood against the artery wall is too high), dysphagia (difficulty swallowing), vascular dementia (brain damage caused by multiple strokes characterized by memory loss in older adults), and atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls). CR #1 died in the facility on the morning of [DATE]. No code status was listed for CR#1 as of [DATE] at 1:04 p.m. Record review of CR #1's Physician Progress Note dated [DATE] revealed she was listed as full code status. Record review of CR #1's Physician Progress Note dated [DATE] revealed she was listed as Do Not Attempt to Resuscitate (DNR/No CPR) status. Record review of CR #1's MDS dated [DATE] revealed she usually made herself understood and sometimes understood others; she had a BIMS score of 02 (severe cognitive impairment); she required extensive physical assistance from at least two staff for bed mobility, transfers, dressing, and personal hygiene (one staff) and she was totally dependent on staff for toilet use and bathing; she ambulated via wheelchair with staff assistance; and she was always incontinent of bowel and bladder. CR #1's code status was not addressed in the MDS. Record review of CR #1's undated care plan revealed she had a code status of DNR (Goal: Status will be maintained. Interventions: Inform staff of code status; Monitor for any changes in CR #1's code status; Monitor for decrease in change of condition and report to doctor; Review code status quarterly and as needed); and she required hospice services (Goal: Dignity will be maintained, and resident will be kept comfortable and pain free within one hour of intervention. Interventions: Admit to hospice; Assist with ADL's and provide comfort measures as needed; Ensure advanced directives are in place per resident and responsible party request'; Monitor for decreased appetite, weight loss, skin break down and report to hospice; Monitor for signs and symptoms of increased pain, discomfort and give medications/treatment- monitor for relief). Record review of CR #1's MAR for [DATE] revealed, Advance Directive: Do Not Resuscitate. Record review of CR #1's progress notes for [DATE] revealed: On [DATE] at 6:40 a.m., LVN A wrote, During morning rounds writer entered resident's room, resident showed no signs of life. Resident's body was warm to touch, no audible breaths noted. Family, hospice, and DON notified. EMS was contacted due to DNR not in place. Hospice nurse and [family member] at bedside when EMS arrived, [family member] stated, she did not want CPR performed on resident. Resident was pronounced [dead] per hospice nurse. Record review of Provider Investigation Report dated and signed by the Administrator on [DATE] revealed at 4:30 a.m. on [DATE], LVN A observed CR #1 with no signs of life. No treatment was provided to CR #1. The investigation findings were inconclusive. In-services were started on code status and DNRs after the investigation. The following summary, completed by the Administrator and DON (their names were typed at the end of the document but there were no signatures) dated [DATE], was attached to the report: To Whom It May Concern: . On [DATE] DON received a phone call stating resident expired around 4:30 a.m., nurse on duty state that family was at bedside and hospice nurse was on her way in when she (the hospice nurse) called facility to notify her (LVN A) that she (the hospice nurse) could not locate an Out of Hospital DNR and did not have one on file. Nurse stated family did not wish to initiate CPR at that time, 911 (were) called with EMS/Police who verified no signs of life in which family restated their wishes to not initiate CPR. Hospice nurse arrived and pronounced death at bedside ([DATE] 6:28 a.m.) and mortician picked up resident to transport to funeral home of resident's choice. Administrator, doctor, police, and HHSC was notified. Nurse on duty, LVN A, stated that order in resident's chart stated, Do Not Resuscitate, DNR binder located on crash cart had resident's name on log when first opened but could not locate an Out of Hospital DNR but trusted that there was one in place since resident was on hospice services. In review of chart, resident started on hospice services on [DATE] and DNR order entered on [DATE]. Per nurse, LVN B, order was received from hospice and given to her from Social Worker to be updated. Care Plan note from Social Worker [DATE] states, RP requested for resident to be given ensure, resident will continue to be DNR and receive long-term services from facility. Per reports from nurse on duty (LVN A), family member verified that Social Worker thought she (the family member) had signed the OOHDNR previously, but she (the family member) never did. LVN A was suspended pending the investigation and ultimately terminated due to not following facility protocol in verifying and OOHDNR is visualized before withholding initiation of CPR. The Social Worker received disciplinary action for inaccurate documentation, failure to follow facility protocol and ensuring documents were current, correct, and accurate. Nurse who entered DNR order (LVN B) into resident's chart without visualizing OOHDNR received disciplinary action . In an interview with the DON on [DATE] at 10:32 p.m., she said LVN A called her the previous morning ([DATE]) around 5:30 a.m. and said during her rounds, she noted CR #1 had coded and expired. She said LVN A told her at that time CR #1's family member was at her bedside and the hospice nurse was on her way to the facility. She said LVN A told her she called the DON because when she (LVN A) heard back from the hospice nurse, the hospice nurse told her CR #1 did not have an OOHDNR on file with them. The DON said she told LVN A to initiate CPR and check the facility's binder for a DNR form on CR #1. She said LVN A told her she could not find a DNR form on CR #1 in the binder or in her chart. The DON said she instructed LVN A to call 911. The DON said LVN A later told her CR #1's family refused CPR and the EMS arrived 5-10 minutes after that. The DON said LVN A told her CR #1's family member refused CPR from EMS as well. The DON said CR #1's family member never said why they did not execute a DNR. The DON said the SW updated the code status book log daily. She said the log for [DATE] had CR #1's name under DNR, but they shred the forms daily. The DON said after the incident with CR #1, the book was audited and updated on [DATE]. In a telephone interview with LVN A on [DATE] at 10:38 p.m., she said she frequently worked with CR #1 (she worked the 6:00 p.m. - 6:00 a.m. shift) and cared for her on Monday, [DATE]. She said when she arrived at her shift on Monday, [DATE], an aide said CR #1 was having trouble breathing. LVN A said CR #1 told her she was ok, and she was not in distress. LVN A said she asked the aide to sit CR #1 up to give her better lung expansion. She said CR #1's vital signs were all normal and she did not complain of pain. LVN A said her next interaction with CR #1 was later in the evening when she went by her room to check on her. She said she heard a little crackle (bubbling) in CR #1's chest and asked her to cough to clear her throat. She said the crackle cleared up after CR #1 coughed and she said she felt better. She said her next interaction with CR #1 was when she checked on her and heard crackling a little more. LVN A said she left the room to see if CR #1 had an order for medication to help the crackling and she saw the order for atropine (used to help reduce saliva, mucus, or other secretions in the airway). She said she gave CR #1 the atropine and later returned at 11:00 p.m. to give her a scheduled pain medication. She said she returned to CR #1's room at 4:30 a.m. and found she had passed away. She said she kept trying to arouse CR #1 because it looked like she was asleep. LVN A said she could tell CR #1 was not breathing because she did not hear the crackle anymore. She said she checked CR #1's vital signs but there was nothing. She said she called CR #1's hospice and the answering service picked up. She said a hospice nurse called her back about 20 minutes later. She said she told the hospice nurse CR #1 had no vital signs and had passed away. She said the hospice nurse told her she was on her way. She said about 20-30 minutes later, the hospice nurse called her back and said there was no DNR on file with hospice. LVN A said she told the hospice nurse they must have had it because it was on all of CR #1's orders. LVN A said she pulled up CR #1's profile on her electronic record and the screen said DNR. She said she went and got the code status binder the facility kept on the crash cart. She said she found CR #1's name on the log sheet, which indicated she was DNR status. She said CR #1 had to have an OOHDNR form because it would not be in their electronic system if she did not. She said she flipped through every page in the code status book and could not locate an actual DNR form for CR #1. She said when the hospice nurse called and said she did not have a copy of CR #1's DNR, she (LVN A) thought that hospice just did not have a copy and not that the DNR form did not exist because she had seen DNR in CR #1's record for months. She said she confidently went to the book and thought the form would be there. She said she was shocked when she did not see a form for CR #1 in the book and she thought the form had to be in the building somewhere. She said she stayed on the phone with the hospice nurse the whole time while she searched for the DNR form and she asked what to do. She said the hospice nurse said since CR #1 passed away and was not coming back, she (LVN A) should call 911, and have CR #1's family say they did not want CR #1 resuscitated. LVN A said she spoke to CR #1's family member and explained the situation. She said the family member said she did not want that (CPR after she passed away) done to CR #1. She said the family member told her she had not signed a DNR, and the SW was previously under impression that she had signed a DNR before. LVN A said when EMS arrived, they asked CR #1's family member about initiating CPR but she refused. LVN A said normally, if she found a resident unresponsive and they had DNR, she would call hospice, the family, the doctor, and the DON. She said if the resident did not have a DNR, she would start CPR immediately. She said she was prepared to initiate CPR for CR #1 after the fact as well. She said she would have done whatever she needed to do to get it right. In a telephone interview with the facility's SW on [DATE] at 11:28 p.m., she said she had not completed a DNR with CR #1 or her family and there was no form on file at the facility. She said in most cases, she would be the person to complete an OOHDNR form at the facility. The SW said the DNR binder was always available at the facility's crash cart. She said she was responsible for updating the log sheet daily from their electronic system in the resident portal. The SW said she previously had a conversation with CR #1's family member, but she could not say exactly when. She said CR #1 was initially full code but then transitioned to hospice. She said she had a care planning meeting with CR #1's family member a few months ago when she transitioned to hospice. She said she could not say the hospice agency said CR #1 was DNR status. The SW said the facility's nurses usually put code statuses in the computer system and they had her as DNR in the electronic system. She said she usually shredded the old papers from the logbook. She said when she looked back at her notes from her conversation with CR #1's family member, the notes said CR #1 would continue to be what she was before, which was DNR according to the electronic record. The SW said she did not realize CR #1 did not have a DNR form because her family member could have filled one out with hospice or one of the facility nurses. She said she had never previously cross-referenced the log sheets with actual forms in the book, but she started auditing each form in the book instead of just putting the code status on the log sheet. She said if a resident was already DNR, there would be a copy in the book. She said she was not checking them before the situation with CR #1. In a telephone interview with CR #1's family member on [DATE] at 8:55 a.m., she said there was a care planning meeting a couple of months ago (she could not recall which month) and the facility's SW mentioned that she had signed an OOHDNR form. The family member said she told the SW she never signed the DNR, and she wanted CR #1 to remain on full code status. She said the social worker with the hospice agency had previously spoken to her about signing a DNR, but she had to talk with another family member first. The family member said she absolutely expected the facility's nurse to initiate CPR on CR #1 when she was found unresponsive. She said the nurse should have saved CR #1's life because she was not terminally ill. She said the facility could not have listed someone as DNR if the papers were never signed. She said LVN A called her on [DATE] at 4:44 a.m. and very nonchalantly said CR #1 passed away. She said EMS was not called until an hour after she got to the facility. She said LVN A approached her about signing a DNR after CR #1 was already dead. In an interview with the DON on [DATE] at 11:30 a.m., she said LVN B told her she received a written order from CR #1's hospice on [DATE] which said she was DNR. The DON said she had searched for the written order, but she could not locate it. She said she asked someone in the medical records department to look for it, but they could not locate the order either. The DON said there was some back and forth about between LVN B and the SW about entering the DNR status change into the system. The DON said she was not sure why LVN B changed CR #1's status to DNR when there was not an actual form presented. She said before [DATE], CR #1 was full code. She said CR #1 was admitted to hospice on [DATE]. The DON said nurses should have an actual DNR form for a resident before they change the code status. She said the SW should coordinate with family or hospice for DNR's. In a telephone interview with CR #1's physician (also the facility's medical director) on [DATE] at 10:48 a.m., he stated his office did not have a DNR form for CR #1. He said the code statuses listed on his progress notes in CR #1's electronic record came from the facility's computer system. He said he did not know who changed code statuses for the facility, but he would have gotten the code status from whomever updated the system. He said he assumed the DNR was already executed and was on file if the electronic health record stated she was DNR. He said he assumed somebody at facility had checked it. In a telephone interview with the hospice agency's Administrator on [DATE] at 11:07 a.m., she stated the hospice agency never had a DNR in place for CR #1. She said there was never any paperwork or order of any kind sent to the facility that indicated CR #1 had a DNR. She said a social worker from the hospice agency attempted to get CR #1's family to execute a DNR but all information they sent to the facility indicated CR #1 was full code status. She said according to the hospice agency notes, LVN A called the on-call hospice nurse on [DATE] at 4:37 a.m. and said she went into CR #1's room and found her unresponsive. She said LVN A told the hospice nurse she had already called CR #1's family. She said the hospice nurse informed LVN A at that time that CR #1 was not on DNR status. She said LVN A told the hospice nurse CR #1 was listed as DNR on their master copy. She said on [DATE] at 5:10 a.m., LVN A called the hospice nurse back and said CR #1 did not have a DNR on file. She said the hospice nurse told LVN A she needed to call 911 and LVN A said CR #1's family was already at her bedside and refused CPR. In a telephone interview with LVN B on [DATE] at 11:20 a.m., she said she changed CR #1's code status in the facility's electronic system in [DATE] when the SW gave her an order signed by the previous medical director to change the code status to DNR. LVN B said CR #1 was going on hospice and that (changing CR #1's code status to DNR) was the last piece to make it official. She said normally, orders went into medical records, but when the DON went to look for it after CR #1 died, nobody could locate it. She said she would never change a code status without someone telling her to do it, but nobody ever told her they needed an actual DNR form to change code status. She said CR #1's was the first time she changed a code status. She said before then, she always handed them off to the facility social workers to change, but the SW had not been there that long. She said she should have done what she usually did and given it to the SW. She said she now knew to look at the actual DNR form before changing the status in the system. She said she thought it was an overall system failure, and not just one person's fault. She said the order was changed in [DATE] and the incident happened in December. She said this information should be reviewed and audited daily. She said if the system worked well, the information should have been caught before CR #1 died. She stated she no longer worked at the facility. In an interview with the Administrator on [DATE] at 12:45 p.m., she stated there was a breakdown in the facility's system and process of changing code status to DNR and it was not executed correctly by staff in place. She said the negative outcome was that CR #1 passed away. She stated the DON, LVN A, and LVN B no longer worked at the facility. Record review of the facility's Advance Directive policy, revised [DATE], revealed, Advance directives will be respected in accordance with state law and facility policy . 6. Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . 19. Changes or revocation of a directive must be submitted in writing to the administrator . The care plan team will be informed of such changes and/or revocations so that appropriate changes can be in the assessment (MDS) and care plan . Record review of the facility's policy on Resident Rights, revised [DATE] revealed, . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . e. self-determination . Record review of facility policy, Conformity with Laws and Professional Standards, revised [DATE] revealed, Our facility operates and provides services in compliance with current federal, state, and local laws, regulations, codes, and professional standards of practice that apply to our facility and types of services provided. 1. Our facility is in conformity with all federal, state, and local laws relating to ., postmortem procedures, resident rights, and confidentiality of information as well as other relevant health and safety requirements . Record review of facility policy, Abuse and Neglect - Clinical Protocol, revised [DATE] revealed, . 2. Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . An Immediate Jeopardy (IJ) was identified on [DATE] at 12:34 p.m. due to the above failures. The Administrator and DON were notified of the IJ and the IJ template was provided on [DATE] at 12:34 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 7:47 a.m. and included the following: PLAN OF REMOVAL Immediate action: 1. An audit was performed on [DATE] by the DNS, ADON; SW on all resident's currently residing in the facility code status (OOHDNR/ Full Code) ensuring code status accurately reflected in the electronic record as well ensuring resident who wish to be OOHDNR have a form completed and in the code book. No other discrepancies were found. 2. An audit was performed on [DATE] by the DNS/Designee to ensure code status are accurate and up to date in the electronic med record PCC and the Code Binder log. No other discrepancies were found. 3. [DATE] LVN A was immediately suspended pending investigation. 4. [DATE] The SW received disciplinary action for inaccurate documentation, failure to follow facility protocol and ensuring documents are current, correct, and accurate. 5. [DATE] The facility DON/Designee verified code status of all residents under hospice care with their respective hospice provider to ensure OOHDNR or Full code status are consistent. No other issues were identified 6. [DATE] The facility Administrator submitted a Self -report to the HHSC complaint line due failure to provide CPR by the assigned Licensed nurse. Investigation of incident initiated at this time. Intake number 395633 Facility's Plan to ensure compliance 7. [DATE] in-service initiated by the DON/Designee with the facility Licensed nurses regarding: License nurses will communicate all new orders received for OOHDNR, resident/RP desire to change status or conflicting/unclear orders information to the Resident, Responsible Party, SW, DON and or Administrator immediately via phone call/ message at any time. This includes new and re-admissions. 8. [DATE] The SW/designee received a 1:1 in-service re: SW will print the DNR report daily Mon-Fri from the electronic records and physically compare it against the actual OOHDNR forms completed during the morning meeting. The Adm/designee will verify process and initial report to indicate accuracy. MOD will run DNR report and compare it against the actual DNR forms, if/when changes are noted MOD will report it to the SW, DON and/or administrator immediately meeting via phone message/call for follow up when if needed. 9. An in-service was initiated by the DON/Designee on [DATE] all staff on the Changes of Condition/code status/CPR process: on residents with a change of condition to include Hospice residents. If the resident is found to be a full code, then immediate implementation of CPR must be initiated and 911 called. If the resident is a DNR the nurse is to visualize OOHDNR form and the responsible party, DON, physician, and hospice, if indicated, will be notified. In-services completed [DATE]. 10. [DATE] The DNS/designee began an in-service the licensed nursing staff on checking the code status when/if resident have a change in condition. If the resident's code status cannot be verified by visualization of the OOHDR the resident will be considered a full code until the necessary, document is in place. Completed [DATE] 11. On [DATE] the DNS/designee began 1:1 in-servicing clinical non-clinical staff on notifying changes in condition to the nurse if the patient is found unresponsive and to obtain verification of OOHDNR/code status and let the licensed nurse know what the code status is. If a resident is a Full Code, then immediate implementation of CPR must be initiated and 911 called. If the resident is a DNR then the physician and family will be notified. The in-service also included initiation of code status if code status is unknown. Completed on [DATE] 12. On [DATE] the DNS/Designee conducted an in-service with social worker and Licensed nurses on the OOHDNR process, including what to do when a OOHDNR is desired by the resident/PR/Physician and at what point the nurses are to update the order of OOHDNR or Full Code. Completed [DATE] 13. [DATE] The DON/designee began a questionnaire to validate effectiveness of training. The random questionnaire is be conducted for both clinical and non-clinical staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Completed [DATE]. 14. The DON/Designee will run the physician orders from prior day, any new order received for a code status change will be immediately verified by actual visualization of OOHDNR forms in the code binder. Issues identified will be immediately corrected. 15. An impromptu QAPI meeting was conducted with the facility Medical Director, on [DATE] and [DATE] to notify him of the potential for noncompliance and the action plan implemented for approval. He approved the plan on [DATE]. 16. The Administrator, DON/Designee will report the findings to the QI process and QA committee monthly. Any concerns or recommendations will be address immediately. 17. When an order for OOHDNR/Full code is added into the electronic medical record the face sheet is automatically updated by the system without the need of staff to make that change. 18. All resident admitted to the facility are either a Full code unless an OOHDNR form is submitted to the facility by the resident or their responsible party. The social worker/administrator verifies accuracy and validity or the documents. Issues identified are immediately addressed with the resident and or RP. Residents who present forms with incomplete, incorrect or with conflicting information remain Full Code until the form is properly completed as per instruction. If the OOHDNR form is valid then a copy is provided to nursing to obtain a physician order, enter the order into the electronic medical record and place the form in the Code Binder. A second copy is provided to Medical Records to upload the document into the resident Medical Record. The resident code status is review by the IDT during the care plan meeting, education to the Resident and or Responsible party on the topic is provided at this time. Monitoring of the plan of removal included: Following acceptance of the facility's Plan of Removal, the facility was monitored from [DATE] to [DATE]. Record review of In-Service Attendance Record dated [DATE] revealed the Administrator educated the SW on DNR Procedures/Policies. The document read in part, The SW will print DNR sheet daily and check against DNR's that are physically in the DNR Book. Will double check PCC to be sure it shows resident code status correctly. Will initial that it is complete. Social Worker will then give completed items to Administrator to check as a second look that all DNR's are present. Record review of In-Service Record dated [DATE] revealed RN C educated the SW, all licensed nurses, other clinical staff, and non-clinical staff on Changes of Condition/Code Status/CPR Process. The document read in part, When a change of condition is noted, or a resident is found unresponsive the staff member will: Immediately get assistance for resident by calling out Code Blue . A staff member will promptly verify code status in the resident's E-chart and the Code Binder to visualized OOHDNR. If the resident's code status is Full Code - CPR will be immediately initiated, 911 will be called and a staff member will bring the crash cart to the resident room. CPR will continue until EMS arrives and takes over . If the resident is noted with code status - DNR the staff member will verify the OOHDNR form is completed and notify the physician, responsible party, and DON/Hospice. If the resident noted with No code status - CPR will be immediately initiated, 911 will be called and a staff member will bring the crash cart to the resident room. CPR will continue until EMS arrives and takes over. The charge nurse will then inform the physician, responsible party, and DON . Record review of In-Service Record dated [DATE] revealed RN C educated the SW, licensed nurses, other clinical staff, and non-clinical staff on Notification of Changes in Resident Condition. The document read in part, Staff will communicate changes in resident condition to the charge nurse immediately utilizing the Stop and watch Tool. The original sheets will be given to the nurse in charge with the written statement of the noted changes to conduct an assessment . Record review of In-Service Record dated [DATE] revealed RN C educated the SW, licensed nurses, other clinical staff, and non-clinical staff on OOHDNR Process. The document read in part, When an order is received for OOHDNR the social worker will coordinate with the resident, the resident responsible party, and the physician to ensure all parties agree and complete the form as per instructions. Once the form is properly completed it is brought up to nursing, then nursing is to change the order to Do Not Resuscitate (DNR) in the resident medical records. The physician is made aware to sign the order and validate resident plan of care changed. A copy of the signed OOHDNR is kept in the Code Binder on top of the crash cart and uploaded into the resident medical record . Record review of In-Service Record dated [DATE] revealed RN D educated the SW, licensed nurses, other clinical staff, and non-clinical staff o[TRUNCATED]